The Parental Stressor Scale: Neonatal Intensive Care Unit (PSS:NICU) is a well-validated tool to assess different sources of stress in parents during the NICU hospitalization of their infant. The present meta-analytic study assessed the relative impact of different NICU-related sources of parental stress in a pool of studies conducted in a wide set of different countries. Also, differences in stress levels by parent gender and country, as well as the impact of infants’ neonatal characteristics and clinical conditions were explored.
Records were searched on PubMed, Scopus, and Web of Science (January 1993–December 2019). A purposive open search string was adopted: [“PSS:NICU”] OR [“PSS-NICU”] OR [“Parental Stressor Scale”]. A multiple random-effect meta-analysis was conducted on data from 53 studies extracted by independent coders.
Parental role alteration emerged as the greatest source of stress for both mothers and fathers. Mothers reported higher stress levels compared to fathers. A significant difference emerged only for the subscale related to sights and sounds physical stimuli. No significant effects of infants’ neonatal characteristics (gestational age, birth weight) and clinical conditions (comorbidities) emerged. A marginal positive effect of NICU length of stay emerged on the global level of parents’ stress.
The current meta-analysis underlines that parental stress related to NICU admission is a worldwide healthcare issue. Immediate and tailored support to parents after the birth of their at-risk infant should be prioritized to reduce parental stress and to promote mothers and fathers’ emotional well-being and new-born neurodevelopmental outcomes.
Your institute does not have access to this article
Open Access articles citing this article.
Impact of psychological distress and psychophysical wellbeing on posttraumatic symptoms in parents of preterm infants after NICU discharge
Italian Journal of Pediatrics Open Access 24 January 2022
Italian Journal of Pediatrics Open Access 02 December 2021
Subscribe to Journal
Get full journal access for 1 year
only $8.25 per issue
All prices are NET prices.
VAT will be added later in the checkout.
Tax calculation will be finalised during checkout.
Get time limited or full article access on ReadCube.
All prices are NET prices.
Chawanpaiboon S, Vogel JP, Moller AB, Lumbiganon P, Petzold M, Hogan D, et al. Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis. Lancet Glob Heal. 2019;7:e37–e46.
Als HB, McAnulty G. The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) with Kangaroo Mother Care (KMC): comprehensive care for preterm infants. Curr Women’s Health Rev. 2011;7:288–301.
Montirosso R, Tronick E, Borgatti R. Promoting neuroprotective care in neonatal intensive care units and preterm infant development: insights from the neonatal adequate care for quality of life study. Child Dev Perspect. 2017;11:9–15.
McCormick MC, Litt JS, Smith VC, Zupancic JA. Prematurity: an overview and public health implications. Annu Rev Public Health. 2011;32:367–79.
Grunau RE. Neonatal pain in very preterm infants: long-term effects on brain, neurodevelopment and pain reactivity. Rambam Maimonides Med J. 2013;4:e0025.
Mäkelä H, Axelin A, Feeley N, Niela-Vilén H. Clinging to closeness: the parental view on developing a close bond with their infants in a NICU. Midwifery. 2018;62:183–8.
Aita M, Johnston C, Goulet C, Oberlander TF, Snider L. Intervention minimizing preterm infants’ exposure to NICU light and noise. Clin Nurs Res. 2013;22:337–58.
Montirosso R, Fedeli C, Del Prete A, Calciolari G, Borgatti R, Mosca F, et al. Maternal stress and depressive symptoms associated with quality of developmental care in 25 Italian Neonatal Intensive Care Units: a cross sectional observational study. Int J Nurs Stud. 2014;51:994–1002.
Grosik C, Snyder D, Cleary GM, Breckenridge DM, Tidwell B. Identification of internal and external stressors in parents of newborns in intensive care. Perm J. 2013;17:36–41.
Carter JD, Mulder RT, Frampton CM, Darlow BA. Infants admitted to a neonatal intensive care unit: parental psychological status at 9 months. Acta Paediatr Int J Paediatr. 2007;96:1286–9.
Purdy IB, Craig JW, Zeanah P. NICU discharge planning and beyond: recommendations for parent psychosocial support. J Perinatol. 2015;35:S24–S28.
Franck LS, Cox S, Allen A, Winter I. Measuring neonatal intensive care unit-related parental stress. J Adv Nurs. 2005;49:608–15.
Provenzi L, Santoro E. The lived experience of fathers of preterm infants in the Neonatal Intensive Care Unit: a systematic review of qualitative studies. J Clin Nurs. 2015;24:1784–94.
Montirosso R, Provenzi L, Calciolari G, Borgatti R. Measuring maternal stress and perceived support in 25 Italian NICUs. Acta Paediatr Int J Paediatr. 2012;101:136–42.
Provenzi L, Fumagalli M, Bernasconi F, Sirgiovanni I, Morandi F, Borgatti R, et al. Very preterm and full-term infants’ response to socio-emotional stress: the role of postnatal maternal bonding. Infancy. 2016;22:1–18.
Welch MG, Hofer M, Brunelli S, Stark RI, Andrews HF, Austin J, et al. Family nurture intervention (FNI): methods and treatment protocol of a randomized controlled trial in the NICU. BMC Pediatr. 2012;12:14.
Flacking R, Lehtonen L, Thomson G, Axelin A, Ahlqvist S, Moran VH, et al. Closeness and separation in neonatal intensive care. Acta Paediatr. 2012;101:1032–7.
Ichijima E, Kirk R, Hornblow A. Parental support in neonatal intensive care units: a cross-cultural comparison between New Zealand and Japan. J Pediatr Nurs. 2011;26:206–15.
Montirosso R, Giusti L, De Carli P, Tronick E, Borgatti R, Mosca F, et al. Developmental care, neonatal behavior and postnatal maternal depressive symptomatology predict internalizing problems at 18 months for very preterm children. J Perinatol. 2018;38:191–5.
Miles MS, Funk SG, Kasper MA. The stress response of mothers and fathers of preterm infants. Res Nurs Health. 1992;15:261–9.
Schappin R, Wijnroks L, Uniken Venema MM, Jongmans MJ. Rethinking stress in parents of preterm infants: a meta-analysis. PLoS ONE. 2013;8:e54992.
Miles MS, Funk SG, Carlson J. Parental stressor scale: neonatal intensive care unit. Nurs Res. 1993;42:148–52.
Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ Open. 2009;339:b2700.
Baía I, Amorim M, Silva S, Kelly-Irving M, de Freitas C, Alves E. Parenting very preterm infants and stress in Neonatal Intensive Care Units. Early Hum Dev. 2016;101:3–9.
Cox C, Bialoskurski M. Neonatal intensive care: communication and attachment. Br J Nurs. 2001;10:668–76.
Feeley N, Sherrard K, Waitzer E, Boisvert L. The father at the bedside: patterns of involvement in the NICU. J Perinat Neonatal Nurs. 2013;27:72–80.
Arockiasamy V, Holsti L, Albersheim S. Fathers’ experiences in the neonatal intensive care unit: a search for control. Pediatrics. 2008;121:e215–e222.
Provenzi L, Barello S, Fumagalli M, Graffigna G, Sirgiovanni I, Savarese M, et al. A comparison of maternal and paternal experiences of becoming parents of a very preterm infant. J Obstet Gynecol Neonatal Nurs. 2016;45:528–41.
Almadhoob A, Ohlsson A. Sound reduction management in the neonatal intensive care unit for preterm or very low birth weight infants. Cochrane Database Syst Rev. 2015;2017:CD010333.
Brown G. NICU noise and the preterm infant. Neonatal Netw. 2009;28:165–73.
Fisher D, Khashu M, Adama EA, Feeley N, Garfield CF, Ireland J, et al. Fathers in neonatal units: improving infant health by supporting the baby-father bond and mother-father coparenting. J Neonatal Nurs. 2018;24:306–12.
Flacking R, Ewald U, Nyqvist KH, Starrin B. Trustful bonds: a key to ‘becoming a mother’ and to reciprocal breastfeeding. Stories of mothers of very preterm infants at a neonatal unit. Soc Sci Med. 2006;62:70–80.
Flacking R, Ewald U, Starrin B. ‘I wanted to do a good job’: experiences of “becoming a mother” and breastfeeding in mothers of very preterm infants after discharge from a neonatal unit. Soc Sci Med. 2007;64:2405–16.
Matricardi S, Agostino R, Fedeli C, Montirosso R. Mothers are not fathers: differences between parents in the reduction of stress levels after a parental intervention in a NICU. Acta Paediatr. 2013;102:8–14.
Bracht M, Kandankery A, Nodwell S, Stade B. Cultural differences and parental responses to the preterm infant at risk: strategies for supporting families. Neonatal Netw. 2002;21:31–38.
Schneider LW, Crenshaw JT, Gilder RE. Influence of immediate skin-to-skin contact during cesarean surgery on rate of transfer of newborns to NICU for observation. Nurs Women’s Health. 2017;21:28–33.
Pasquier J-C, Blouin S, Daigle K, Corriveau S, Thibodeau D, Goffaux P. 767: immediate skin-to-skin contact after caesarean delivery to improve neonatal pain tolerance. Am J Obstet Gynecol. 2013;208:S322.
Hane AA, Myers MM, Hofer MA, Ludwig RJ, Halperin MS, Austin J, et al. Family nurture intervention improves the quality of maternal caregiving in the neonatal intensive care unit: evidence from a randomized controlled trial. J Dev Behav Pediatr. 2015;36:188–96.
Welch MG, Halperin MS, Austin J, Stark RI, Hofer MA, Hane AA, et al. Depression and anxiety symptoms of mothers of preterm infants are decreased at 4 months corrected age with Family Nurture Intervention in the NICU. Arch Women’s Ment Health. 2016;19:51–61.
Welch MG. Calming cycle theory: the role of visceral/autonomic learning in early mother and infant/child behaviour and development. Acta Paediatr. 2016;105:1266–74.
Almgren M. Benefits of skin-to-skin contact during the neonatal period: governed by epigenetic mechanisms? Genes Dis. 2018;5:24–26.
Linnér A, Almgren M. Epigenetic programming—The important first 1000 days. Acta Paediatr Int J Paediatr. 2020;109:443–52.
Moen A. If parents were a drug? Acta Paediatr Int J Paediatr. 2020;109:1709–10.
Abdeyazdan Z, Shahkolahi Z, Mehrabi T, Hajiheidari M. A family support intervention to reduce stress among parents of preterm infants in neonatal intensive care unit. Iran J Nurs Midwifery Res. 2014;19:349–53.
Aftyka A, Rozalska I, Rybojad B, Samardakiewicz ME. Polish version of the parental stressor scale: neonatal intensive care unit. Ann Agric Environ Med. 2019;26:67–72.
Akbari N, Moradi Z, Sabzi Z, Mehravar F, Fouladinejad M, Asadi L. The effect of narrative writing on fathers’ stress in neonatal intensive care settings. J Matern Neonatal Med. 2019;0:1–6.
Akkoyun S, Tas Arslan F. Investigation of stress and nursing support in mothers of preterm infants in neonatal intensive care units. Scand J Caring Sci. 2019;33:351–8.
Barkin JL, Stausmire JM, Te MN, Pazik-Huckaby A, Serati M, Buoli M, et al. Evaluation of maternal functioning in mothers of infants admitted to the neonatal intensive care unit. J Women’s Heal. 2019;28:941–50.
Cheng C, Franck LS, Ye XY, Hutchinson SA, Lee SK, O’Brien K. Evaluating the effect of Family Integrated Care on maternal stress and anxiety in neonatal intensive care units. J Reprod Infant Psychol. 2019;00:1–14.
Dabas S, Joshi P, Agarwal R, Yadav RK, Kachhawa G. Impact of audio assisted relaxation technique on stress, anxiety and milk output among postpartum mothers of hospitalized neonates: a randomized controlled trial. J Neonatal Nurs. 2019;25:200–4.
Ionio C, Mascheroni E, Colombo C, Castoldi F, Lista G. Stress and feelings in mothers and fathers in NICU: identifying risk factors for early interventions. Prim Heal Care Res Dev. 2019;20:1–7.
Marshall A, Guillén Ú, Mackley A, Sturtz W. Mindfulness training among parents with preterm neonates in the neonatal intensive care unit: a pilot study. Am J Perinatol. 2019;36:1514–20.
Masri S, Charafeddine L, Tamim H, Naamani M, Jammal T, Akoury-Dirani L. Validation of the Arabic Version of the Parental Stressor Scale: Neonatal Intensive Care Unit (PSS: NICU). J Clin Psychol Med Settings. 2019. [Epub ahead of print].
Ong SL, Abdullah KL, Danaee M, Soh KL, Soh KG, Japar S. Stress and anxiety among mothers of premature infants in a Malaysian neonatal intensive care unit. J Reprod Infant Psychol. 2019;37:193–205.
Pichler-Stachl E, Urlesberger P, Mattersberger C, Baik-Schneditz N, Schwaberger B, Urlesberger B et al. Parental stress experience and age of mothers and fathers after preterm birth and admission of their neonate to neonatal intensive care unit; a prospective observational pilot study. Front Pediatr. 2019; 7.
Pisoni C, Spairani S, Manzoni F, Ariaudo G, Naboni C, Moncecchi M, et al. Depressive symptoms and maternal psychological distress during early infancy: a pilot study in preterm as compared with term mother–infant dyads. J Affect Disord. 2019;257:470–6.
Varma JR, Nimbalkar SM, Patel D, Phatak A. The level and sources of stress in mothers of infants admitted in neonatal intensive care unit. Indian J Psychol Med. 2019;41:338–42.
Çekin B, Turan T. The stress levels of parents of premature infants and related factors in nenoatal intensive care units. Turk J Pediatr. 2018;60:117–25.
Küçük Alemdar D, Kardaş Özdemir F, Güdücü Tüfekci F. The effect of spiritual care on stress levels of mothers in NICU. West J Nurs Res. 2018;40:997–1011.
Noergaard B, Ammentorp J, Garne E, Fenger-Gron J, Kofoed PE. Fathers’ stress in a neonatal intensive care unit. Adv Neonatal Care. 2018;18:413–22.
Pisoni C, Spairani S, Fauci F, Ariaudo G, Tzialla C, Tinelli C, et al. Effect of maternal psychopathology on neurodevelopmental outcome and quality of the dyadic relationship in preterm infants: an explorative study. J Matern Neonatal Med. 2020;33:103–12.
Al Maghaireh DF, Abdullah KL, Chong MC, Chua YP, Al Kawafha MM. Stress, anxiety, depression and sleep disturbance among Jordanian mothers and fathers of infants admitted to neonatal intensive care unit: a preliminary study. J Pediatr Nurs. 2017;36:132–40.
Barr P. Factor analysis of the Parental Stressor Scale in parents of term and near-term surgical newborns. J Reprod Infant Psychol. 2017;35:286–97.
De Bernardo G, Svelto M, Giordano M, Sordino D, Riccitelli M. Supporting parents in taking care of their infants admitted to a neonatal intensive care unit: a prospective cohort pilot study. Ital J Pediatr. 2017;43:1–11.
Kardaş Özdemir F, Küçük Alemdar D. Supporting of the fathers to visit their infants in neonatal intensive care unit decreases their stress level: a pretest–posttest quasi-experimental study. Community Ment Health J. 2017;53:490–5.
Sánchez-Veracruz MJ, Leal-Costa C, Pastor-Rodríguez JD, Díaz-Agea JL. Relationship between satisfaction and stress levels identified in parents with children admitted to a Neonatal Intensive Care Unit. Enferm Glob. 2017;16:281–91.
Diffin J, Spence K, Naranian T, Badawi N, Johnston L. Stress and distress in parents of neonates admitted to the neonatal intensive care unit for cardiac surgery. Early Hum Dev. 2016;103:101–7.
Gustafson KW, LaBrecque MA, Graham DA, Tella NM, Curley MAQ. Effect of parent presence during multidisciplinary rounds on NICU-related parental stress. J Obstet Gynecol Neonatal Nurs. 2016;45:661–70.
Ionio C, Colombo C, Brazzoduro V, Mascheroni E, Confalonieri E, Castoldi F, et al. Mothers and fathers in NICU: the impact of preterm birth on parental distress. Eur J Psychol. 2016;12:604–21.
Kadivar M, Seyedfatemi N, Akbari N, Haghani H, Fayaz M. Evaluation of the effect of narrative writing on the stress sources of the parents of preterm neonates admitted to the NICU. J Matern Neonatal Med. 2017;30:1616–20.
Månsson C, Jakobsson U, Lundqvist P. Translation and psychometric evaluation of a Swedish version of the parental stressor scale PSS: NICU. Scand J Caring Sci. 2016;30:193–201.
Pichler-Stachl E, Pichler G, Baik N, Urlesberger B, Alexander A, Urlesberger P, et al. Maternal stress after preterm birth: Impact of length of antepartum hospital stay. Women Birth. 2016;29:e105–e109.
Umasankar N, Sathiadas MG. Maternal stress level when a baby is admitted to the neonatal intensive care unit at Teaching Hospital Jaffna and the influence of maternal and infant characteristics on this level. Sri Lanka J Child Heal. 2016;45:90–94.
Kadivar M, Seyedfatemi N, Akbari N, Haghani H. The effect of narrative writing on maternal stress in neonatal intensive care settings. J Matern Neonatal Med. 2015;28:938–43.
Rhoads SJ, Green A, Mitchell A, Lynch CE. Neuroprotective core measure 2: partnering with families - exploratory study on Web-camera viewing of hospitalized infants and the effect on parental stress, anxiety, and bonding. Newborn Infant Nurs Rev. 2015;15:104–10.
Samra HA, McGrath JM, Fischer S, Schumacher B, Dutcher J, Hansen J. The NICU Parent Risk Evaluation and Engagement Model and Instrument (PREEMI) for neonates in intensive care units. J Obstet Gynecol Neonatal Nurs. 2015;44:114–26.
Wormald F, Tapia JL, Torres G, Cánepa P, González MA, Rodríguez D, et al. Stress in parents of very low birth weight preterm infants hospitalized in neonatal intensive care units. A multicenter study. Arch Argent Pediatr. 2015;113:303–9.
Alkozei A, McMahon E, Lahav A. Stress levels and depressive symptoms in NICU mothers in the early postpartum period. J Matern Fetal Neonatal Med. 2014;27:1738–43.
Beheshtipour N, Baharlu SM, Montaseri S, Razavinezhad Ardakani SM. The effect of the educational program on Iranian premature infants’ parental stress in a neonatal intensive care unit: a double-blind. Int J Community Based Nurs Midwifery. 2014;2:240–50.
Pritchard VE, Montgomery-Hönger A. A comparison of parent and staff perceptions of setting-specific and everyday stressors encountered by parents with very preterm infants experiencing neonatal intensive care. Early Hum Dev. 2014;90:549–55.
Woodward LJ, Bora S, Clark CACC, Montgomery-Hönger A, Pritchard VE, Spencer C, et al. Very preterm birth: maternal experiences of the neonatal intensive care environment. J Perinatol. 2014;34:1–7.
Ballantyne M, Benzies KM, Trute B. Depressive symptoms among immigrant and Canadian born mothers of preterm infants at neonatal intensive care discharge: a cross sectional study. BMC Pregnancy Childbirth. 2013;13:1–10.
Busse M, Stromgren K, Thorngate L, Thomas KA. Parents’ responses to stress in the neonatal intensive care unit. Crit Care Nurse. 2013;33:52–59.
Chourasia N, Surianarayanan P, Bethou A, Bhat V. Stressors of NICU mothers and the effect of counseling-experience from a tertiary care teaching hospital, India. J Matern Neonatal Med. 2013;26:616–8.
Gonya J, Nelin LD. Factors associated with maternal visitation and participation in skin-to-skin care in an all referral level IIIc NICU. Acta Paediatr Int J Paediatr. 2013;102:53–56.
Franck LS, Oulton K, Nderitu S, Lim M, Fang S, Kaiser A. Parent involvement in pain management for NICU infants: a randomized controlled trial. Pediatrics. 2011;128:510–8.
Ahn YM, Kim NH. Parental perception of neonates, parental stress and education for NICU parents. Asian Nurs Res (Korean Soc Nurs Sci). 2007;1:199–210.
Lau C, Hurst NM, Smith EO, Schanler RJ. Ethnic/racial diversity, maternal stress, lactation and very low birthweight infants. J Perinatol. 2007;27:399–408.
Meyer EC, Garcia Coll CT, Seifer R, Ramos A, Kilis E, Oh W. Psychological distress in mothers of preterm infants. J Dev Behav Pediatr. 1995;16:412–7.
Miles MS, Funk SG, Kasper MA. The neonatal intensive care unit environment: sources of stress for parents. AACN Clin Issues Crit Care Nurs. 1991;2:346–54.
This study was supported by funds from the Italian Ministry of Health to IRCCS Mondino Foundation (“Ricerca Corrente 2020”, “5 per mille”) and to Fondazione IRCCS Policlinico San Matteo (“Ricerca Corrente 2020”).
Conflict of interest
The authors declare that they have no conflict of interest.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Caporali, C., Pisoni, C., Gasparini, L. et al. A global perspective on parental stress in the neonatal intensive care unit: a meta-analytic study. J Perinatol 40, 1739–1752 (2020). https://doi.org/10.1038/s41372-020-00798-6
Impact of psychological distress and psychophysical wellbeing on posttraumatic symptoms in parents of preterm infants after NICU discharge
Italian Journal of Pediatrics (2022)
Journal of Perinatology (2022)
Italian Journal of Pediatrics (2021)